Financial How to file a short-term disability claim

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Disability insurance

How to file a short-term disability claim

UnitedHealthcare Specialty Benefits is committed to supporting you during your period of disability and helping you achieve a timely and healthy return to work.

An important first step is providing you with information on how to file a short-term disability (STD) claim, what you can expect during the claim review process, and what benefits and services are available once your claim is approved.

Claim filing.

You, your employer and your attending physician(s) must complete various claim forms. In some cases, you must provide additional information so we can begin to review your claim.

As an employee, you must submit the following forms and information:

? Employee short-term disability statement: This form includes the information we need to initiate your claim. You may be required to provide additional information, such as copies of other income entitlement awards and/or denials you have received from such sources as workers' compensation, retirement, state disability or others, including those you have applied for but not yet been awarded. (If you receive an award or denial after submitting your claim, please forward this information immediately)

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? Authorization for the Release of Information: This form gives us permission to gather additional information we need to properly administer your claim

? Authorization of Personal Representation: This form is optional. If you would like us to discuss your claim with anyone, we need your prior authorization. If you do not complete the form now, you can request it directly from us after your claim for benefits has been submitted

Your employer must submit the following forms and information:

Your employer can submit these completed materials to us on your behalf, or they can give them to you, and you can send the materials to us with your completed forms.

? Employer's Report of Claim: This form includes information we need to initiate your claim Your employer may be required to provide the following additional information: ??Job description (detailed duties) ??Copy of enrollment card (if employees contribute to plan premium) ??Copy of approved Evidence of Insurability form (if required at plan enrollment) ??Documentation of earnings, including prior year's W-2 ??First Report of Accident form and decision (if a workers' compensation claim was filed) ??Copies of other source(s) of benefits awarded or applied for, but not yet approved (such as Social Security, workers' compensation, retirement, state disability or others) ??Copy of your employment application or resum?, if available

Your attending physician must submit the following forms:

? Attending Physician's Statement: Provide this form to your physician to complete. This form includes information necessary to initiate your claim. In addition, your physician(s) may be required to provide information such as medical records, physician notes, test results and so forth. This information will be requested by UnitedHealthcare on your behalf

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Claim review.

When all necessary information has been received, a claims specialist will be assigned to review your claim and make a determination. The claims specialist will:

? Acknowledge by phone or letter that your claim has been received and is in review ? Request any additional information needed for a claim determination ? Contact your employer to confirm any outstanding information and discuss

return-to-work plans, if appropriate ? Contact your employer and/or attending physician(s) to clarify your condition, discuss

potential for recovery and determine a plan for your return to work ? Make a determination on your claim as soon as possible ? Ensure that your claim receives thorough, fair and objective evaluation We appreciate your prompt response to any requests the claims specialist makes for information, which will help us make a timely determination of benefits available to you under your plan. If a claim decision is delayed while awaiting information, the claims specialist will provide you with a written or verbal status of your claim every 30 days.

We encourage you to complete and submit the necessary materials in a timely manner so your claim can be processed without delay. When you file promptly, a claims specialist can initiate the claims process and begin communicating with all parties, which ultimately helps facilitate a timely determination of your claim. Forms must be complete and all forms must be received before the claims review process can begin.

Mail or fax completed forms and supporting documentation to:

UnitedHealthcare Specialty Benefits P.O. Box 7466 Portland, ME 04112-7466 Fax: 1-888-505-8550

Claim determination.

If your claim is approved, you will receive a weekly benefit payment to help you meet your ongoing financial obligations. In addition, your claims specialist will assist you throughout your recovery and return to work.

? Income replacement benefits: The weekly benefit amount paid to you will be equal to a percentage of your pre-disability earnings, up to a maximum amount stated in your benefit plan for each day you remain disabled as defined by your plan

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?? Timing: You will begin receiving the weekly benefit when you have completed the Elimination Period, which begins the day you became disabled as defined by your benefit plan and ends after a period of time determined by your benefit plan. Your weekly benefit will be paid in arrears. For example, if your disability occurred on January 1 and the Elimination Period ended January 7, the first eligible benefit period would be January 8 to January 15 (7 days). The first weekly benefit check would be payable for the period January 8 to January 15, and the check would be released on January 12

??Benefit reductions: Your weekly benefit amount will be reduced by legally required taxes or deductions, as well as other sources of income outlined in your Certificate of Coverage, such as sick pay, vacation pay, workers' compensation, state disability or other sources outlined in your benefit plan

? Claim management services: Your claims specialist will maintain contact with you, your employer and your physician(s) for the duration of your claim. This individual will monitor your recovery process for the duration of your claim and assist you with next steps

If your claim is denied, you will receive an explanation, along with instructions on how to appeal the decision.

If you have questions about the claims process, please call us at 1-888-299-2070.

For specific information about your Short-Term Disability insurance plan, please refer to your Certificate of Coverage.

This is intended to provide general information and does not change any terms of the STD Certificate of Coverage or Summary Plan Description. In the event of a conflict between the language in this brochure and your STD Certificate of Coverage or Summary Plan Description, the STD Certificate of Coverage and Summary Plan Description will prevail. Please refer to your Certificate of Coverage or contact UnitedHealthcare Specialty Benefits for information regarding exclusions and limitations under your policy and the terms under which your policy may be continued in force or discontinued.

Please note: Any person who knowingly, and with intent to injure, defraud or deceive an insurance company, files a statement of claim containing any false, incomplete or misleading information, may be guilty of a felony, and may be subject to imprisonment, fines and civil damages. In certain states, other consequences may apply.

UnitedHealthcare Disability products are provided by UnitedHealthcare Insurance Company; and in California by Unimerica Life Insurance Company; and in New York by Unimerica Life Insurance Company of New York. UnitedHealthcare Insurance Company is located in Hartford, CT; Unimerica Life Insurance Company is located in Milwaukee, WI; and Unimerica Life Insurance Company of New York is located in New York, NY.

Specialty benefits and programs may not be available in all states or for all group sizes. Components are subject to change.

100-10958 01/12 ?2012 United HealthCare Services, Inc.


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